Carotid artery stenting: Current state of evidence and future directions

Abstract

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published longterm outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis. K E Y W O R D Scarotid artery atherosclerosis, carotid artery stenosis, carotid artery stenting, carotid endarterectomy, stroke, stroke prevention | 319 LAMANNA et AL.

Partial endothelial-to-mesenchymal transition (EndMT) contributes to lumen re-organization after carotid artery ligation

“…Carotid artery stenosis is known to reduce blood flow to the brain and cause strokes. Surgical treatments include carotid endarterectomy and carotid artery stenting, both of which aim to open up the stenotic area 43 . Alternatively, prevention of risk factors for atherosclerosis, such as hypertension, hyperlipidemia (dyslipidemia), and diabetes, as well as the use of antiplatelet agents, is a common internal medical treatment strategy for carotid artery stenosis.…”

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…Similar to complex aortic arch anatomy, severe ICA or CCA tortuosity (defined as the presence of kinks with acute angulation less than 90 degrees, loops with a 'C' or 'S' shaped curvature and two or more areas of angulation less than 90 degrees, or coils with full 360 degree turns) demands increased CMT through often-fragile vasculature [84,85]. Furthermore, turbulent hemodynamics create lumen that is difficult to navigate [84][85][86][87], and excessive curve necessitate flexible stents to prevent kinking, often requiring an open cell design, which in itself can create further challenges in the context of complex plaque morphology [79,88]. Severe tortuosity also increases the difficulty of EPD employment, which is reported with varied effectiveness in reducing atheroembolic events [79].…”

Management of Cervico-Cranial Arterial Dissections

“…In both studies, the aneurysm persisted in the majority of cases, ranging from 67 to 95%, despite the absence of clinical complications. Interventional treatment options can be surgical or EVT, including ligation, resection, bypass procedures, clipping, coiling, and stenting (including multiple, overlapping stents), and trials comparing therapies have been conducted [76][77][78][79][80][81]. As mentioned in the previous section entitled "Endovascular management of extracranial dissections," there are risks associated with EVT which need to be considered in each case.…”